Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Get this document free

The economic impact of dengue hemorrhagic fever on family level in dengue fever

VIEWS: 41 PAGES: 3

									ORIGINAL ARTICLE
                                                                                      Abbreviations
                                                                                      DF        Dengue fever
                                                                                      DHF       Hemorrhagic dengue fever
The economic impact of dengue                                                         DSS       Dengue shock syndrome
                                                                                      ELISA     Enzyme-Linked ImmunoSorbent Assay
hemorrhagic fever on family level                                                     IV
                                                                                      OSVAL
                                                                                                Intravenous
                                                                                                Mandatory, independent, free of choice thesis

in Southern Vietnam                                                                   USD
                                                                                      WHO
                                                                                                American dollars
                                                                                                World Health Organization
                                                                                      GNI       Gross national income
Mette Lønstrup Harving, MD, &
Frederikke Falkencrone Rönsholt, medical student
                                                                                    both the virus and the mosquito vectors resulting in an increased
                                                                                    frequency of epidemics, thus making ground for hyperendemic ar-
University of Copenhagen and Children’s Hospital No. 1, Ho Chi Minh City,           eas [3]. DHF is now among the commonest causes of hospitaliza-
Vietnam                                                                             tion of children in South-East Asia [4].
Correspondence: Frederikke Falkencrone Rönsholt, Rebekkavej 27 st. th.,                The study aimed at measuring the economic consequences of hav-
2900 Hellerup, Denmark.                                                             ing a member of ones family admitted with DHF. This is part of the
E-mail: frederikkefr@gmail.com                                                      quantification of the disease burden, a parameter in the distribution
                                                                                    of funds for health care and research in order to target health inter-
Dan Med Bull 2007;54:170-2                                                          ventions and to provide a comparable measure for intervention [5].
                                                                                       So far no studies from Vietnam concerning this subject have been
ABSTRACT                                                                            published.
Dengue fever is a viral infection transmitted by mosquitoes (Aedes Aegypti).           The study has been made as an OSVAL II thesis at the University
WHO estimates that 40% of the world’s population live in areas endemic for          of Copenhagen.
dengue fever, and that there are approximately 50 million cases of dengue in-
fection worldwide every year.
                                                                                    METHODS
This study aims to measure the economic consequences of dengue hemor-
rhagic fever in Southern Vietnam on family level. Estimating the economic           METHOD
impact of dengue fever/dengue hemorrhagic fever is important in order to            The study is based on standardized interviews of the patients’ par-
prioritize resources for research, prevention, and control. So far no studies       ents/caretakers (appendix 1).
from Vietnam concerning this subject have been published.                              The questionnaire consists of two parts, a data part (items 1-9)
The study is based on standardized interviews. The study includes 175 chil-         and an interview part (items 10-18).
dren at the age 0-15 years, hospitalized in Children’s Hospital No 1 in Ho Chi         The data part deals with age, gender, address, grade of disease,
Minh City during a 10-week period in the fall of 2005. The children’s par-
ents/caretakers were interviewed on expenses related to the child’s disease.        ELISA confirmation, number of admission days (spent in semi-
The study shows that the average family cost of treating one child is approxi-
                                                                                    emergency room and normal room), and the hospital bill.
mately 61 USD including direct and indirect costs. On average, the largest             The interview part is a standardized interview chart and deals
expenses were those related to the initial visit at a local general practitioner,   with the family cost of the child’s illness besides the hospital bill
the hospital bill from Children’s Hospital No1 and lost income for the par-         from the dengue hemorrhagic department.
ents.                                                                                  The questionnaire includes both direct (hospital bills, doctor vis-
Dengue hemorrhagic fever is a large expense for a family and can rightly be         its, additional laboratory tests, and medication) and indirect costs
considered as a substantial socio-economic burden in Southern Vietnam.
Larger studies are needed for a more accurate estimate of the extent of the
                                                                                    (lost income, transportation, food, and other expenses due to in-
expenses related to both dengue fever and dengue hemorrhagic fever.                 convenience).
                                                                                       The families were also asked about the means of funding the dir-
                                                                                    ect costs (whether it was their own funding, insurance, or govern-
INTRODUCTION                                                                        mental/hospital contribution).
Dengue fever (DF) is a viral infection transmitted by mosquitoes
(Aedes Aegypti). The infection can manifest itself as flu-like DF or                POPULATION
as hemorrhagic dengue fever (DHF) with plasma leakage and the                       The population consisted of children admitted to the Dengue Hem-
risk of shock and death. DHF is divided into four grades according                  orrhagic Fever Department in Children’s Hospital No 1, Ho Chi
to clinical symptoms and severity, grade I being the mildest form                   Minh City, with the diagnosis DHF in the period from August 25.
and grade IV the most severe. Grade III and IV constitute the den-                  2005 to November 3, 2005. The patients were not randomized for
gue shock syndrome (DSS) with incipient or profound shock.                          the study, but were chosen at random without previous knowledge
                                                                                    of the economical status of the family.
– Grade I: Fever, non-specific symptoms, positive tourniquet test*                     The inclusion criteria were:
  and/or easy bruising.
– Grade II: Spontaneous bleeding in addition to the manifestations                  – age: 0-15 years
  of grade I.                                                                       – clinically diagnosed as having DHF according to guidelines [1]
– Grade III: Circulatory failure manifested by rapid, weak pulse,                   – diagnosis confirmed by ELISA test
  and narrowing pulse pressure or hypotension.
– Grade IV: Profound shock with undetectable blood pressure and                     The exclusion criteria were:
  pulse.
                                                                                    – insufficient data obtained in the interview
There is no specific treatment for DF. The patients are treated with                – other chronic diseases
paracetamol, oral rehydration and IV fluids according to WHO’s
guidelines [1].                                                                     The patients were examined and diagnosed by doctors from the
  WHO estimates that DHF is endemic in over 100 countries and                       Dengue Hemorrhagic Fever Department. The patients were referred
that 40% of the world’s population is living in risk areas [2]. The                 to the department from the hospital’s outpatient ward, private doc-
past years have shown an expansion of geographical distribution of                  tors, or rural hospitals thus making the population a mixed group of

170                                                                                                         DANISH MEDICAL BULLETIN VOL.   54   NO.   2/MAY 2007
residents of Ho Chi Minh City and provinces surrounding the city.                                         Table 3. Average expenses according to grade of disease. An F-test (vari-
  Personal data, grade of disease, infusion status, number of days                                        ance-ratio test) on the total expense values gives an F-value of 14.85
                                                                                                          (P<0.0001). The expenses increase significantly with the severity of the
admitted, and hospital bill were obtained from the patients’ charts
                                                                                                          disease.
  The parents/caretakers of the children included in the study were
                                                                                                          Grade of                                 Direct cost   Indirect cost    Total cost
interviewed bedside on the day of discharge by a Vietnamese speak-                                        disease                            N     (USD)          (USD)            (USD)
ing doctor from the department and either of the authors.
                                                                                                          I. . . . . . . . . . . . . . . .     7   20.17         19.56             39.72
  The population was divided into groups according to grade of
                                                                                                          II . . . . . . . . . . . . . . .   123   23.62         26.20             49.82
disease (grade I-IV) and type of treatment (patients not requiring                                        III. . . . . . . . . . . . . . .    39   55.78         35.78             91.55
infusions, patients requiring only crystalloid infusions, patients re-                                    IV . . . . . . . . . . . . . .       6   84.29         42.51            126.80
quiring colloid infusions). Table 1 shows the composition of the
population.
                                                                                                          Table 4. Average expenses according to type of treatment. An F-test
                                                                                                          (variance-ratio test) on the total cost values gives an F-value of 41.12
ETHICS                                                                                                    (P<0.0001). The expenses increase significantly when starting or intensify-
The study was approved by The Scientific and Ethical Committee of                                         ing IV fluid treatment.
Children’s Hospital No 1. No written, informed, consent was ob-                                                                                    Direct cost   Indirect costs   Total cost
                                                                                                          Treatment                          N     (USD)         (USD)            (USD)
tained in the study. The participants gave oral consent. Participation
did not involve any expenses or inconveniences for the family.                                            No infusions. . . . . .            82    17.76         21.49             39.25
                                                                                                          Crystalloid . . . . . . .          60    30.45         32.46             62.90
                                                                                                          Colloid . . . . . . . . . .        33    74.05         39.42            113.43
RESULTS                                                                                                   ................................

The average cost for a family with a child having DHF is 61.36 USD,
of which 32.73 USD are direct costs and 28.73 USD are indirect                                            DISCUSSION
costs. Table 2 shows the average expenses divided in direct and indi-                                     The average family cost of treating one child with DHF is approximately
rect expenses, Table 3 and Table 4 show the expenses according to                                         61 USD including direct and indirect costs. Considering that the gross
grade of disease and type of treatment.                                                                   national income (GNI) per capita in Vietnam in 2005 was 620 USD [6],
                                                                                                          61 USD is a large figure and more than an average monthly salary.
                                                                                                             Calculating the cost does not take into account that children un-
Table 1. Population.
                                                                                               N     %    der 6 years of age who are citizens of Ho Chi Minh City (n=17) are
                                      Age, years
                                                                                                          paid for by the government, and it does not take into account that
                                      <1 . . . . . . . . . . . . . . . . . . . . . . . . .       5    3   some patients (n=23) have insurance to cover their direct costs. Nor
                                      1-<5 . . . . . . . . . . . . . . . . . . . . . . .        31   18   does it consider that more than one child in a family can get DHF.
                                      5-<10 . . . . . . . . . . . . . . . . . . . . . .         66   38   These factors cause an underestimation of the family cost.
                                      10-15 . . . . . . . . . . . . . . . . . . . . . .         73   42
                                                                                                             The distribution of cost is shown in Table 2. It shows that the larg-
                                      Gender                                                              est average single expense is the initial doctor visit. This expense is
                                      Male . . . . . . . . . . . . . . . . . . . . . . .        94   54   often larger than the entire hospital stay at Children’s Hospital No 1.
                                      Female . . . . . . . . . . . . . . . . . . . . .          81   46      Besides this, loss of income is a considerable expense. The chil-
                                                                                                          dren are accompanied by their parents/caretakers at all times. The
                                      Address
                                      HCMC . . . . . . . . . . . . . . . . . . . . . .         108   62
                                                                                                          parents/caretakers take care of washing, feeding and looking after
                                      Province . . . . . . . . . . . . . . . . . . . .          67   38   the children. These chores are not done by the staff. Thus most par-
                                                                                                          ents loose their entire income during the time their child is admit-
                                      Grade of disease                                                    ted, while other children are accompanied by older siblings, grand
                                      I. . . . . . . . . . . . . . . . . . . . . . . . . . .     7    4
                                                                                                          parents or unemployed parents.
                                      II . . . . . . . . . . . . . . . . . . . . . . . . . .   123   70
                                      III. . . . . . . . . . . . . . . . . . . . . . . . . .    39   22      The cost of treatment increases significantly with the severity of the
                                      IV . . . . . . . . . . . . . . . . . . . . . . . . .       6    3   disease and the intensity of treatment. These two factors are naturally
                                                                                                          co-bound as long as the patients are treated according to the WHO
                                      Treatment                                                           guidelines. There is a considerable price difference between the treat-
                                      No infusions. . . . . . . . . . . . . . . . .            82    47
                                      Crystalloid . . . . . . . . . . . . . . . . . .          60    34
                                                                                                          ments, as a dose of lactate ringer, which is the first choice crystalloid,
                                      Colloid . . . . . . . . . . . . . . . . . . . . .        33    19   costs 0.40 USD and a dose of Dextran, first choice colloid, costs 7.31
                                                                                                          USD [7]. All fluids and medication are paid for by the families.
                                                                                                             Even though the children with higher grade of disease are in the
Table 2. Average expenses divided in direct and indirect expenses.                                        semi-emergency room longer, this has no effect on the family cost,
                                                                                Average amount in USD     as a bed in the semi-emergency room costs the same as a bed in a
Costs                                                                           (range in USD)            normal room.
Direct costs                                                                                                 Similar studies have been conducted in Thailand and Cambodia.
Hospital bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.65 (2.31-125.75)         Coincidentally, Clark et al [4] also found the average financial loss for
Doctor visits/ admission to local                                                                         one family to be approximately 61 USD in Thailand in 2005. This fig-
  hospital and medication* . . . . . . . . . . . . . . . . . . . 12.46 (0-158.23)
                                                                                                          ure includes both direct and indirect cost, however it accounts for
Laboratory tests not included in
  hospital bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        3.62 (0-101.27)        both DF and DHF which leads to the assumption that the figure for
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.73 (5.34-198,.29)    DHF alone must be higher. The Clark et al. study includes patients of
                                                                                                          all ages, but patients over 15 years only constitute a small percentage.
Indirect costs                                                                                               Van Damme et al [8] (Cambodia, 2004) come to the result that
Loss of income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.78 (0-126.58)
Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    6.56 (0-75.95)
                                                                                                          when using a combination of private and public health care provid-
Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.29 (0-63.29)           ers, which was most frequently the case for the patients in our study,
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.63 (0-177.22)          the average direct cost was 32 USD (32.73 in our study). Like Clark
Total direct and indirect costs . . . . . . . . . . . . . . . . . 61.36 (5.34-280.57)
                                                                                                          et al’s study, however, Van Damme et al’s study includes all ages and
                                                                                                          both DF and DHF.
*) Medication is most often given by a doctor and included in the bill from the doc-
   tor. Most people can’t differentiate what amount is spent on medications and what
                                                                                                             Okanurak et al [9] found, in 1997, that the family cost per child
   amount is for the doctor’s visit itself.                                                               with DHF was 118.29 USD in Bangkok and 102.82 USD in rural ar-

DANISH MEDICAL BULLETIN VOL.               54   NO.    2/MAY 2007                                                                                                                       171
eas in Thailand when including direct and indirect costs. The differ-            western military personnel [10]. There is probably a long way to go
ence in costs between Thailand and Vietnam is most likely explained              regarding the development of a pediatric vaccine against DF not to
by the economic differences between the two countries. Thailand is               mention the implementation in the national immunization pro-
a richer country with higher price levels and higher GNI per capita,             grammes in those developing countries needing it most.
whereas Vietnam has extremely low wages and, as a result, lower                     There are, of several reasons, problems with the financing of the
hospitalization fees – even if these are quite expensive to the average          development of the vaccine. The disease and its extent is not com-
Vietnamese family.                                                               monly recognized in Western countries, where the money for re-
   Van Damme et al’s DF/DHF study from Cambodia shows that                       search is, and it is not the type of research that produces fast and
many families had to take loans or sell possessions in order to pay              tangible results that can be presented to potential investors. Further-
for health services, leading to indebtedness and poverty. Even                   more the purchasers of the vaccine are developing countries with
though Cambodia is a somewhat poorer country than Vietnam,                       limited funds. Thus the funds for DF research are to be found in
these findings are likely to be applicable to Vietnam as well.                   non-governmental organizations and governmental financial aid
   Several DF vaccines are under development but none are close to               from Western countries, where the distribution of means, however,
approval. They are primarily targeted towards adult travellers and               is dependent on media attention and other kinds of publicity.
                                                                                    Increased awareness of the existence and extent of DF/DHF may be
Appendix                                                                         part of solving the expanding problem that DF constitutes worldwide.
Economic impact of DHF: Questionnaire
                                                                                 CONCLUSION
Date:                               Case number:                                 The aim of the study was to estimate the cost for a family, when a
                                                                                 child is admitted with DHF. The result was an average of 61 USD,
Date of admission:                  Date of discharge:                           when both direct and indirect costs were included. With a GNI per
                                                                                 capita of 620 USD this is a substantial financial loss to the average
Chart data
Information to be obtained from patient’s chart                                  Vietnamese family.
                                                                                    The family cost increases significantly with the grade of disease
1. Name/hospital no. _______________________________________________             and thereby with the intensity of treatment, since all fluids and med-
                                                                                 ications are paid for by the family.
2. Age __________ years
                                                                                    The study illustrates that DF/DHF is a considerable socio-eco-
3. Sex               M      F                                                    nomic burden in Southern Vietnam.
                                                                                    Quantification of disease burden is of importance in accelerating
4. Address           HCMC                          Province                      the introduction of a potential DF vaccine.
                                                                                    In order to estimate the entire burden of disease due to dengue vi-
5. Grade of DHF      I              II             III        IV
                                                                                 rus, a larger study including both DF and DHF, all age groups, and
6. Diagnosis confirmed by ELISA :                                                several hospitals is needed.

  Ordered date: _____               Positive       Negative                      ACKNOWLEDGEMENTS
7. IV fluids         None           Crystalloids              Colloids
                                                                                 We wish to thank the staff at the Dengue Hemorrhagic Fever De-
                                                                                 partment and the staff at the Department of Microbiology at Chil-
8. No of admission days (days in emergency / days                                dren’s Hospital No 1 in Ho Chi Minh City for their help with trans-
   in normal room)                                            _____/_____ days   lation, blood sampling and analysis. Special thanks to MD Freddy
                                                                                 Karup Pedersen, our supervisor on the OSVAL II thesis, and head of
9. Total hospital bill presented to family modified to
   cheapest room price                                        __________ VD      department Dr. Nguyen Thanh Hung whose invaluable help made
                                                                                 this project possible.
                                                                                    The authors received funding from RUF, Oticon Fonden, Hotel-
Family level data                                                                ejer Anders Månssons mindelegat and De Københavnske Uddan-
                                                                                 nelses legater.
To be asked the parent/caretaker on patient’s discharge
                                                                                 *) >20 petechiae per square inch appearing after applying pressure to the
10.   No of days ill prior to admission                       __________ days    arm with a blood pressure cuff for five minutes.

11.   Parent/caretaker’s number of days away from work __________ days
                                                                                 References
12.   Parent/caretaker’s estimated daily income               __________ VD       1. Dengue haemorragic fever, diagnosis, treatment, prevention and control.
                                                                                     III. Treatment. Geneva: World Health Organisation, 1997:24-33.
13.   Amount spent on medications prior to admission          __________ VD       2. www.searo.who.int/en/Section10/Section332.htm/ 16. Dec. 2006
                                                                                  3. Gubler DJ. Epidemic dengue/ dengue hemorrhagic fever: A global public
14.   Amount spent on doctor visits/admission to                                     health problem in the 21st century. Dengue bull 1997;21.
      local hospitals prior to admission                      __________ VD       4. Clark DV, Mammen PM jr, Nisalak A et al. Ecconomic impact of dengue
                                                                                     fever/ dengue hemorrhagic fever in Thailand at the family and popula-
15.   Additional laboratory tests                             __________ VD          tion levels. Am J Trop Med Hyg 2005;72:786-91.
                                                                                  5. Murray CJL. Quantifying the burden of disease: The technical basis for
16.   Estimated transport expenses                            __________ VD          disability-adjusted life years. Bull WHO 1994;72:429-45.
                                                                                  6. http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIP.
17.   Extra expenses on food                                  __________ VD          pdf /12. Oct. 2006
                                                                                  7. Internal hospital records.
18.   Means of payment:                                                           8. Van Damme W, Van Leemput I et al. Out-of-pocket health expenditure
                                                                                     in poor households: evidence from Cambodia. Trop Med Int Health
18a. Family’s own funds                                                              2004;9:273-80.
                                                                                  9. Okanurak K, Sornmani S, Indaratna K: The cost of dengue hemorrhagic
18b. Insurance                                                     ________ %        fever in Thailand. Southeast Asian J Trop Med Public Health 1997;28:
                                                                                     711-7.
18c. Government/hospital contribution                              ________ %    10. Deen JL. The challenge of dengue vaccine development and introduc-
                                                                                     tion. Trop Med Int Health 2004;9:1-3.

172                                                                                                        DANISH MEDICAL BULLETIN VOL.   54   NO.   2/MAY 2007

								
To top